Provider Demographics
NPI:1053301051
Name:LARSON, JENNIFER P (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:P
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10874 KIMBALL PL
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1306
Mailing Address - Country:US
Mailing Address - Phone:810-531-0851
Mailing Address - Fax:
Practice Address - Street 1:451 W LINCOLN AVE STE 100
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-2912
Practice Address - Country:US
Practice Address - Phone:714-503-6550
Practice Address - Fax:714-409-3075
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075468207Q00000X
MAMA229851207Q00000X
CAC164590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH20610Medicare UPIN
MAA40570Medicare PIN
MI080162063OtherMETRAHEALTH
MA124818OtherFALLON
MA95815301OtherNETWORK HEALTH
MAAA78115OtherHARVARD PILGRIM HEALTH CARE
MI7041248OtherAETNA
MI4508204001OtherCIGNA
MIH20610Medicare UPIN
MIH20610OtherHEALTH ALLIANCE PLAN
MA495575OtherTUFTS HEALTH PLAN
MAA40570Medicare PIN
MIH20610OtherHEALTH NET FEDERAL
MI253116OtherHEALTH ADVANTAGE NETWORK
2061478OtherUNITED HEALTH CARE